slide 1 impulse control disorders in tourette’s syndrome · slide 1 cathy l. budman, md director,...

Cathy L. Budman, MDDirector, Movement Disorders Program in

PsychiatryNorth Shore-LIJ Health System

Professor PsychiatryHofstra University School of Medicine

NJCTS Webinar April 9, 2014

Impulse Control Disorders

in Tourette’s Syndrome

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Speaker Disclosures:

Grant Support: Astra Zeneca , Otsuka, Psyadon

Medical Advisory Board: LI-TSA, LI-CHADD, TSA-CDC

Discussion of off-label and/or investigational use:yes X no ___

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Common Psychiatric Disorders in TS

The Impulse Control Disorders“Want to do’s”

Obsessive Compulsive Spectrum Disorders“Have to do’s”

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Impulsivity

Predisposition to rapid, unplanned reactions to internal or external stimuli without regard to negative consequences for self or others

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6 Compulsivity

Predisposition to performing actions, often of a trivial and repetitive nature and often against one’s will, aimed at reducing unpleasant or anxious internal or external states

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8 Impulsive/ Compulsive Spectrum Disorders

Intermittent Explosive Disorder Self-injurious Behaviors Trichotillomania Compulsive Gambling Eating Disorders Kleptomania Body Dysmorphic Disorder Non-obscene socially

inappropriate symptoms (NOSIS)

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Impulse Control Disorders (ICDs) in Adults with TS

74.2% of sample (n=33) had at least one ICD Intermittent Explosive Disorder 51.6% Compulsive Buying Disorder 41.9% Compulsive Computer Use 22.6% Kleptomania 12.9% Trichotillomania 9.7% Pyromania 9.7% Body Dysmorphic Disorder 6.5%

(Frank et al. 2011)

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Causes of Impulse Control Symptoms in Tourette Syndrome

Psychiatric comorbidity Medication side effects/interactions Executive dysfunction Alcohol/substance abuse Home, school, occupational stress Tic severity

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11 Neurobiology of Impulse Control Disorders with Repetitive Behaviors

“The Reward Deficiency Syndrome”

Traits characterized by:

dysfunction in brain’s reward cascade

increased risk for multiple impulsive, compulsive, and addictive behavioral propensities

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12 Neurotransmitters

Dopamine (DA)

Norepinephrine (NE)

Serotonin (5HT)

GABA

Glutamate (NMDA)

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Neurotransmitters Regulate DifferentAspects of Mood, Cognition, and Behavior

Stahl SM. Essential Psychopharmacology. 2nd ed. New York, NY: Cambridge University Press; 2000.Foote SL et al. In: Bloom FE and Kupfer CJ et al. Psychopharmacology. 1995.

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14 Dopamine Pathways

Functions:•reward (motivation)•pleasure,euphoria•motor function•compulsion•perseveration•decision making

Serotonin Pathways

Functions:•mood•memory•sleep•cognition

nucleusaccumbens

hippocampus

striatum

frontalcortex

substantianigra/VTA

raphe

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Aggressive Symptoms in Tourette Syndrome

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Adaptive Aggression

Aggressive Behaviors in Animals:

• Dominance Behaviors

• Territorial Aggression

• “Female” Aggression

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17 Developmental

Aggression:

TemperTantrums

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18 Developmental Aggression

“Temper Tantrums”

Occurs < 1/3 children ages 3-12 years Most common: ages 3-5 years (75%) Least common: ages 9-23 (4%) More common: boys > girls (3:1) Hx: trauma, seizure, tics*, hyperactivity,

bedwetting, head banging, sleep problems

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Pathological Aggression

Aggressive behavior that is:

Excessive in intensity, duration, frequency Inappropriate to expectable social context May be directed toward self, loved ones, others Age-inappropriate

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20 Types of Pathological Aggression:Proactive / Non-impulsive / Predatory

Onset around age 6.5 years Associated with aggressive role models Accompanied by decreased autonomic

activationExamples: bullying, delinquency/sociopathy

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21 Pathological Aggression:

Proactive Type

Psychopathy

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Types of Pathological Aggression:Reactive/Impulsive/”Maladaptive”

Onset approx. age 4.5 years Can be associated with history of abuse/trauma Accompanied by increased autonomic

activation Examples: “rage attacks”, affective storms

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23 Overview

Rage and Episodic Dyscontrol:• occurs in significant number of TS patients• causes considerable morbidity• is leading reason for residential placement• symptoms are poorly understood• treatments are nonspecific

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24 Neurobiology of Aggression

• DA, opioids, androgens, ACTH facilitate sexual behavior & aggression

• Serotonin (5HT) and NE, possibly via neuromodulators GABA and glutamate mediate inhibitory responseso Central 5HT disturbances linked

with aggression & impulsivityo Low central 5HT associated with

violenceo Lesions of PFC or OFC linked

with aggression

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Causes of Aggressive Symptoms

• Alcohol/substance abuse• Medication side effects• Toxins• Neurological conditions• Physical/sexual/emotional abuse• Pain• Sleep disorders • Pre-existing psychopathology

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26 Causes of Aggressive Symptoms

Medications: • Benzodiazepines• Steroids• Psychostimulants*• Guanfacine• Neuroleptics• SSRIs & other antidepressants*• Anticonvulsants*

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27 Medication-related Aggression

• Medication-induced activation• Disinhibition• Paradoxical reactions• Behavioral toxicitySx: Irritability, anger/rage, excitabilityhyperactivity, agitation, mood lability

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DSM-V Diagnostic Criteria for Oppositional Defiant Disorder

Pattern of angry/irritable mood, argumentative/defiant behavior or vindictiveness lasting at least 6 months with > 1 person non-sibling, including at least 4 of following symptoms:

• Often loses temper

• Touchy, easily annoyed

• Angry/resentful

• Argumentative with authority figures

• Defies or refuses to comply with rules or requests

• Deliberately annoys others

• Spiteful and vindictive at least 2x in past 6 months

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29 DSM-V Diagnostic Criteria for Intermittent Explosive Disorder (IED)

Recurrent behavioral outbursts with failure to control aggressive impulses, manifested by either:

Verbal aggression (e.g. temper tantrums, tirades, verbal arguments) or,

Physical aggression toward property, animals, or others occurring 2X weekly for about 3 months without serious damage or,

3 behavioral outbursts in past 12 months that resulted in serious damage of property, physical assault to others or animals

• Magnitude of aggression is grossly out of proportion to provocation/stress

• Outbursts are not pre-meditated

• Outbursts cause marked distress, impairment, or financial/legal consequences

• Chronological age at least age 6 years

• Not better explained by other mental/medical disorder or substance

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30 Prevalence & Correlates of DSM-IV IEDThe National Co-morbidity Survey Replication

9282 people ages 18 and olderface-to-face household survey

Lifetime prevalence: 5.4% - 7.3% 12-month prevalence: 2.7% - 3.9% Widely distributed in the population Usually begins in childhood or adolescence Significantly comorbid with mood, anxiety, and substance

disorders Only 28.8% ever received treatment for their anger

(Kessler et al. 2006)

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Aggressive Symptoms in TS

Common in clinical settings Impulsive type most typical Complex etiology Cause severe morbidity Treatment still largely non-specific

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International TS Database

3,500 TS cases in 22 countries

37% anger control problems ever

26% anger control problems now <10% anger control problems TS only

(Freeman et al.1999)

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Explosive Outbursts and TS:Clinical Phenomenology

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Explosive Outbursts in TS:

• Abrupt, unpredictable episodes of severe physical and/or verbal aggression

• Grossly out of proportion to any provocation

• Experienced as uncontrollable & distressing

• Accompanied by physiological activation

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35 Clinical phenomenology of episodic rage in children with TS

48 children with TS + rage ages 7-17 yearsFactor and cluster analyses revealed four homogeneous subgroups:

Specific Urge Resolution Environmentally Secure Reactivity Nonspecific Urge Resolution Labile Non-Resolving

(Budman, Rockmore, Stokes, Sossin 2003)

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36 Prevalence and Clinical Correlates of Explosive Outbursts in TS

218 patients from 2 large samples TS(CR, US)

20% had explosive outbursts Clinical correlates:

CR: lower age onset tics, tic severityUS: ADHD, tic severity, prenatal nicotine exposure

(Chen K et al. 2013)

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Explosive Outbursts in TS Children

Explosive outbursts are symptoms These symptoms are possibly related to tic severity These symptoms appear associated with specific

psychiatric disorders, certain current psychotropic usage, environmental factors(Sukhodolsky et al 2003; Budman et al. 2003, 2000,1998; Stephens and Sandor, 1999)

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38 Assessment of Rage Symptoms in TS

Detail nature of outbursts in terms of:

frequency severity duration triggers context

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39 Treatment of Rage Symptoms in TS

Comprehensive Evaluation

Diagnosis: medical, psychiatric, neuropsychological psychosocial assessment

Medications: side effects, drug interactions

Psychosocial function: family, school/work, peers

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Treatment of Rage Symptoms in TS

Atypical antipsychotics: risperidone*, aripiprazole*, olanzapine*, ziprasidone, quetiapine

SSRIs: fluoxetine, sertraline, fluvoxamine, citalopram, paroxetine*

Anticonvulsants/Mood Stabilizers: Lithium, divalproex, lamotrigine, carbamazepine, topiramate

Other: psychostimulants, propranolol, clonidine, mecamylamine, EFAs

* published pilot studies in TS

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41 Treatment of Rage Symptoms in TS

Psycho-education Parent Skills Training Family Therapy/Marital Therapy Social Skills Training Collaborative Problem Solving Strategies Anger Management programs Dialectical behavioral therapy Relapse prevention therapy Anti-Bullying Programs Physical exercise, nutrition, sleep hygiene

(Scahill et al. 2006; Green et al. 2003)

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42 Trichotillomania

Occurs in .02 – 3% patients with TS

Repetitive hair pulling

More common: TS + OCD >TS only or OCD only Treatment: Habit Reversal Therapy, tic suppressants

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Self-injurious Behaviors (SIB)

Non-suicidal self-injury/ deliberate destruction of one’s body in the absence of intent to die

Often associated with:Mood Disorders Autism/PDDPTSD Personality DisordersSubstance Abuse Eating DisordersDisruptive Behavior Disorders

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44 Self-injurious Behaviors (SIB)

Occur in 14-60% of patients with TS Mild SIB appear associated with OCS Severe SIB associated with affective

and/or impulse dysregulation:head banging punchingslapping orifice diggingself-biting pinchinghitting picking

(Mathews et al. 2004)

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45 Coprophenomena in TSInternational Tic Consortium

15 sites, 7 countries world-wide

597 prospectively entered consecutively patients seen between 2005-2008

506 children< 18 years, 91 adults

Coprolalia: 19.3% males, 14.6% females , mean age onset = 11 years

Copropraxia: 5.9% males, 4.9% females

Coprophenomena: associated with number of other repetitive behaviors, spitting, reported tic severity, comorbity especially OCD

(Freeman et al. 2008)

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Coprophenomena

Socially/contextually inappropriate verbal expressions, gestures, or complex behaviors

Typically vulgar, profane, insulting, but not expressed out of conscious anger or frustration

Occurs in 17.6% children, 28.6% adults

Not necessary for diagnosis of TS

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48 Copropraxia

Occurs in 1- 6% of patients with TS

Grabbing genitals Touching others sexually Pelvic Thrusting Picking at buttocks Obscene gestures

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Surveyed 87 adolescent or adult outpatients with TS

• 22% reported insulting other

• 5% reported making other non-obscene comments

• 14% other socially-inappropriate behaviors

• Most often associated with comorbid ADHD and ODD

(Kurlan et al. 1996)

Non-obscene Complex Socially Inappropriate Behaviors in TS

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Study of 60 patients with TS at specialty clinic found that approx 2/3 experience NOSIS

NOSIS associated with:

obsessions, attention problems, coprolalia, conduct disorder

Increased premonitory urges

Increased tic severity

Decreased quality of life (QOL)

Non-obscene socially inappropriate symptoms (NOSIS) and TS

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20 adults with TS-alone compared with 20 aged-matched controls on two social judgment tasks:

Regulation of behavior during emotional self-disclosure tasks

Mental judgment of others’ behavior on a “faux pas test”

No differences in ratings of inappropriateness on self-disclosure task

Adults with TS-alone impaired relative to controls in detecting socially

inappropriate behaviour on faux pas test

Some evidence of executive dysfunction in the TS-alone group.

(Channon S et al. 2012)

Non-obscene socially inappropriate symptoms (NOSIS) and TS

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Clinical Case Example:Jillian is a 12 year old female with TS/OCD/ADHD who lives

with her mother during the weekdays and spends every other weekend with her father, her step-mother, and her 17 year old step-brother. She is taking Concerta, Intuniv, and was recently started on Zoloft.

Jillian has been experiencing explosive outbursts at her mother’s home only, usually in response to limit-setting and when her requests are met with “no” by her mother.

What factors must be considered when evaluating Jillian’s symptoms?

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53 Clinical Case: Points of Discussion

How often do these episodes occur?

What is happening before, during, and after these outbursts occur?

What time of day do these episodes occur?

How does Jillian feel afterwards?

Is this a medication side effect or drug interaction?

Does Jillian have any additional psychiatric comorbidities?

Is Jillian being bullied at school?

Is Jillian being abused physically or sexually?

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54 Additional Information TS and Related Disorders

National Tourette Syndrome Association (TSA) 42-40 Bell Boulevard, Bayside, NY 11361 tel. 718 224-2999

New Jersey Center for Tourette Syndrome (NJCTS)50 Division StreetSomerville, New Jersey 08876tel. 908-575-7350

Children and Adults with ADHD (CH.A.D.D.) 81 Professional Place, Suite 201 Landover, MD 20785 tel. 301 306-7070

Obsessive Compulsive Foundation, Inc. (OCF) 90 Depot St., P.O. Box 70 Milford, CT 06460-0070 tel. 203-878-5669

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slide 1 impulse control disorders in tourette’s syndrome · slide 1 cathy l. budman, md director,...

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